a team approach to therapy

Journal of Family Therapy (1982) 4: 271- 284

A team approach to therapy*

Bebe Speed?, Philippa Seligmant , Philip Kingston$ and Brian CadeT

Introduction

There have been a number of discussions in the family therapy literature of various models of live supervision and consultation. Some writers such as Montalvo (1973), Birchler (1975), Haley (1976), Gershenson (1978) and Cade and Seligman (1 982) have written about aspects of the supervision of trainees using a one-way screen. Olson and Pegg (1979) d' lscuss a model of live supervision which utilizes a supervisor, trainee therapist and as many as nine other trainees forming a team operating in the therapy room. Cornwell and Pearson (1981) have written about live supervision focusing extensively on the team aspects of a trainee group working behind a screen. Literature on peer therapist consultation, by comparison, is more sparse but similarly various models are described. Smith and Kingston (1980) discuss the use of a single consultant (called by them a supervisor) in the same room as the therapist and family. Nielsen and Kaslow (1980) elaborate six models of peer consultation but exclude peer consultation teams whereas Papp (1977, 1980), de Shazer (1980) and Boscolo and Cecchin (1982) discuss the use of the latter but relatively briefly, the focus of these three papers being something other than peer consultation in teams.

This paper, by comparison, will have as its focus peer consultation in teams and, in particular, teams which operate by using a one-way screen. As Hoffman (1981) points out, the advent of one-way screens in the 1950s offered two therapeutic positions, that of the therapist and that of the observer. Seeing differently made it possible to think differently, not only about a family but also about the relationship between therapist and family, the family-plus-therapist system. It has

Received December 1981; revised version received March 1982. * Many of the ideas in this paper were originally presented at a workshop given by the

t The Family Institute, 105 Cathedral Road, Cardiff. t Bristol University, and The Family Institute, Cardiff.

first two authors at the Association of Family Therapy Conference, York, 1981.

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0163-4445/82/030271+ 12 $03.00/0 @ 1982 The Association for Family Therapy

272 B. Speed et al.

been discovered by some therapists (see Olsen, 1979, and Smith and Kingston, 1980), obliged to work without a one-way screen, that such a perspective can be gained by taking a consultant/supervisor r81e whilst in the therapy room and in that way remaining relatively separate. Whilst recognizing that a one-way screen is hence not mandatory for a model of therapy using live team consultation, the use of such a screen will be assumed in this paper.

Team formation

Boscolo and Cecchin (1982) point to the importance of team members sharing the same ‘epistemological model’, that is, a way of concep- tualizing behaviour which is common to all. Basic clashes will inevitably arise in a team where, for example, one member views agoraphobic behaviour as a consequence of the individual’s maladaptive learning, another sees it as a consequence of unresolved internal conflict and a third as an expression of a dilemma belonging to the whole family, solved through the development of the symptom. Nevertheless, a principal reason for using a team is the difference of perspective provided by different team members which, hopefully, produces a more adequate view of the family and its difficulties and more ideas about what to do. The point about difference is that it leads to such richness. If differences are, however, too fundamental, they may lead to competition and con- fusion with some team members struggling to impose their definitions of ‘reality’ on others. It seems important, therefore, that potential team members discover each other’s orientation to therapy before the team begins work. Like Cornwell and Pearson (1981) the authors of this paper had previously worked together in various combinations before the team was established and already knew and respected each other’s work. In some settings, such knowledge is not necessarily easily available and people may only subsequently find a team unviable because of profound theoretical disagreements.

Our experience, like that of Boscolo and Cecchin (1982), also suggests the necessity of a ‘fit’ on a personal level between team members and a concomitant absence of serious interpersonal conflicts. It seems, for example, important that the different ways in which team members behave, though sometimes irritating in the short term, are valued in the long term. One team member’s tendency to wish to understand in a step by step fashion can be valued overall though it may jar in a moment when others have intuitively grasped an overall pattern which is difficult as yet to explain in a logical, step by step way. Similarly, tendencies in team

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members to jocularity and free association may sometimes be frustrating to others who behave in a more solemn way but the joking is nevertheless valued, in the long term, for its contribution to creative hypotheses and interventions and more generally to uplifting the mood of the team when it is down.

One difficulty, which may not be perceived as such when a team initially forms, is the potential imbalance produced by differing levels of contact between team members outside of formal team time. In our team, three members work together full-time and the fourth joins them one day a week. There is a risk that the three can inadvertently exclude the fourth by discussing cases or making decisions in his absence. There is also the risk that the team as a whole can somehow begin to define the three as the ‘real’ team and the fourth as a visitor. Such difficulties can be mitigated by telephone contact outside team time when necessary, by the restrictions of team business to team time as far a possible and by the absent member’s trust of the other three.

What may prove more difficult, are the different levels of expertise which inevitably develop according to how members spend their time outside of the team. For example, a team of two social work lecturers and two general practitioners who only work as family therapists when they meet, are not likely to get ahead of each other in their therapy expertise. In our team, by comparison, the three members who work together full- time are engaged entirely in the teaching and practice of family therapy, whilst the fourth member spends most of his time lecturing in social work. Because of this imbalance, the three had become more experienced in family therapy than the fourth which led, for a period of time, to some tensions. (This issue has now been openly discussed and after debating possible solutions to the problem, we have decided that the fourth member will take a more specialized, research r81e in the team.)

One crucial aspect of a team’s formation is the place of that team in its wider setting. Palazzoli et al. (1978) for example, discuss potential difficulties related to the operation of a team in the setting of Italian Institutional Psychiatry such as pressure to publish research data and the imposition on the team of new members. Their fears that such pressures could disturb the smooth functioning of the team led them to estab- lishing themselves completely independently of public institutions. Additionally, teams are potentially more effective and more powerful than individuals and may pose a threat within more traditionally organized settings; for example, a team with backgrounds in psychiatric nursing, working in a hospital setting may upset the traditional pattern of authority relationships between doctors and nurses. Even if

274 B . Speed et al.

hierarchical pressures are minimal, issues may arise vis-&vis colleagues: Hoffman (1981) highlights the problem of envy which may arise from other tolleagues towards a team perceived as exclusive and effective.

In retrospect, our team paid insufficient attention, at the time of its attempted formation, to the implications of its establishment for the wider agency. Though the Cardiff Family Institute has for a long time used a team approach both within the staff group and in training, when a specialist team was first mooted, the size of the agency rendered difficult the formation of such a subsystem. Factors which finally made it possible were, firstly, the appointment of a new staff member which enabled working alliances to develop outside of the proposed new team; secondly, members of the new team reassured other staff of their continuing involvement with the agency as a whole, including agreeing initially to work together fortnightly rather than the weekly meeting that had previously been planned. It seems necessary that a team should be sufficiently freed from the wider setting so that boundaries are firm enough to allow its development. At the same time, those boundaries must be permeable enough to prevent the production of a rigid insider/ outsider dynamic which would be destructive to the agency and to the team. As time has passed, the relationship between the team and the rest of the agency has become much easier, at least in part because other ventures were establishedsuch as a collaboration between a team member and a non-team colleague in sex therapy which has been one bridge amongst many others between the team and the rest of the agency.

The team as a system

One of the difficulties often faced by teams in their formative stages, as suggested earlier, is a difference in the levels of therapeutic expertise amongst members of the team. There may be more ‘senior’ members, whose greater experience in a particular approach may give rise to a number of possible reactions amongst ‘junior’ members; for example, acquiescence and dependence on a senior member or rebellion and competition. As the junior members become more expert, this can be experienced by others as an assault by ‘upstarts’ on the seniors’ integrity or as a welcome and productive development. In our team, there have been a number of manoeuvres in this area though competitiveness has diminished considerably as we have been able to recognize openly each other’s growing expertise in different facets of the therapeutic enterprise. Humour is also used as an effective way of defusing tensions arising from competition: it is well known in the team, for example, that when there

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are articles and papers to be written, our grammar expert first does the punctuation and then the others fill in the words.

Problems may arise from differential status in a team emanating not from actual therapy expertise but from professional status distinctions such as that of psychiatrist and social worker. It may be some time before a team from mixed professional disciplines see themselves as equal as far as status is concerned. A further complication may occur when one team member, though apparently ‘equal’ in the team, has responsibilities outside the team which are viewed by the team perhaps covertly and the outside world overtly as conferring more power and authority on that team member. The obvious example is a family therapy team, one of whose members is also the consultant in charge of a unit which is a source of patients and their families for the therapy team to treat. (See Hildebrand et al., 1981 .)

When teams form, it may be a problem for some members to move from operating relatively independently to operating in a team context. Some may tend to remain too independent whereas others may tend to fall into too great a dependency. The use of the telephone, linking consultants with therapist illustrated this in our team. It was some time, after a number of arguments and discussions, before we evolved our present system of turn-taking on the telephone and the acceptance that, if necessary, one team member can ’phone a message through uni- laterally, without clearing this with fellow consultants. Such relatively trite aspects of a team’s functioning can often be highly symbolic and, therefore, produce an apparently disproportionate degree of tension. Whilst a degree of independence may have to be sacrificed for the sake of the smooth running of a team there are risks that too much independence is forfeited resulting in comfortable but unproductive agreement. Therapists, working in teams, may over time lose their individual perspectives and the team perspective, as an amalgam of those individual perspectives, may in consequence suffer. This tendency in our team is somewhat counteracted by our relationship with other agency staff members and with other therapists and colleagues outside of the agency.

Whilst a team may induce sameness, it can also, paradoxically, encourage difference in that a team has the built-in advantage of providing a regular forum for discussion. When time is available, we argue extensively and often productively about theoretical matters. A theme which continually preoccupies us for example, is the relationship between individuals and their families. How far is it possible to focus on individuals without losing sight of their relational context and vice versa?


An illustrative example of this dilemma is the case of a young woman who had not spoken for three years. A systemic hypothesis was formu- lated to account for this and an intervention, positively connoting the woman’s behaviour, was made to her and her family. At a subsequent interview, to which the woman came alone, one of the consultants suggested that the woman be requested to practice mouthing words without speaking or to try whistling in an attempt to gradually induce speech. The therapist decided to use neither suggestion because they were both directed at the individual and the symptom alone. They seemed illogical to her at that time in terms of the overall systemic hypothesis which had defined the woman’s decision to stop talking as crucially helpful to her family.

Teams may find it appropriate to have a number of explicit rules to help facilitate their functioning. As was illustrated above, it may, for example, be helpful to have an explicit rule which gives the therapist power of veto when there are disagreements between consultants and therapists about what to do. Even though power of veto has been agreed, the therapist may at times allow the consultants’ perceptions to take precedence over hidher own, recognizing that the consulting group often has greater objectivity. But this is probably only possible after a considerable time has been spent working together during which trust in each other’s work and judgement has built up.

Occasionally, disagreements between team members can become more extreme. As Palazzoli et al. (1978) indicate, frustration and anger often originate in the relationship between team and family when the therapist and consultants have somehow become entangled in the family’s web. Clarity is lost and the team transfer frustration with the family on to each other. In a similar way, our team has observed how rapidly our view of a family as dull, leading to feelings of boredom and lethargy in the team, is transformed when a new hypothesis or interesting intervention is hit upon. A one-way screen can be highly permeable in both directions; the behaviour of the consultants frequently being influenced by the family as the family’s behaviour is frequently influenced by the consultants.

Stress and tension may also arise in a team with the advent of visitors coming to observe the team at work. In a team’s early days, when relationships are still relatively uncertain between team members, outsiders may seem threatening and intrusive. Initially, our team found that, because of a tendency to be on our best behaviour and present a united front, we were unwilling or unable to deal adequately with disagreements in the presence of visitors. Difficulties in our relationships thus

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escalated and we would then often deal less competently with families. What seemed to be most at issue in the team at those times was the question of competence and being seen to be competent by one’s team and by visiting therapists. We decided to deal with this by, firstly,limiting visitors to once a month until we felt more secure and, secondly, by giving ourselves permission to disagree publicly. The stress of visitors has generally diminished considerably and we have hence been able to make better use of the stimulation which visitinggroups provide. Nevertheless, we know that some visitors, because of our perception of their status or because they are perceived by us as potentially critical, can still threaten us. On those occasions we work hard to help each other avoid destructive competitiveness and support each other as much as possible.

The relation between team and family

How consultants and therapist work together with a family is partially related to how many members form the team; a team of two will necessarily operate differently from a team of four. It is difficult to determine the optimal size for a team. A team of two may have fewer disagreements but be relativelymore sterile and less creative. Additionally, there will be more occasions when one team member has to work alone because of the other’s absence than will occur in a team of more than two. A team of three may have to deal with the well documented problems of triangles, that is, managing issues arising around coalitions between pairs with the third left out. A team of four may subdivide into two parts, an ‘us and them’ situation. Larger teams, though creative, may tend towards more chaos.

The team’s style is also inextricably linked with its theory and techniques of therapy; the two aspects develop out of and continually inform each other. In the Cardiff team each therapy session, for the purposes of description, can be roughly divided into four stages: (a) a pre-session discussion of strategy for the interview which, if it is a first session, concentrates largely on an initial hypothesis concerning the problem and its context based on available referral information (b) focused question- ingof the family, both about the problem and relationships in the family context, aimed at confirming or disconfirming the initial hypothesis; (c) the evolution of a hypothesis concerning the family which most adequately fits what we see and (d) the construction of an intervention which is intended to block existing dysfunctional patterns of relating in the family and allow new patterns to emerge.

The consultancy group is crucial to this sequence of therapy along


every step of the way. Before the family arrives, the consultants help the therapist to evolve a working hypothesis on the basis of the referral information, if this is sufficiently detqiled, so that the therapist does not go blindly into the session but has a framework around which to ask questions. When a team is well established, this may take a relatively short time because the team draws on classes of hypotheses developed over time and communicates about them in shorthand. So, for example, a consultant may only have to say ‘vertical marriages’ for the rest of the team to know what hypothesis is intended. Even at this early stage, the consultants, being less involved than the therapist, can be particularly helpful in considering wider aspects of the context of the referral itself. For example, they may notice that the therapist is over-anxious to be successful with the family in order to impress the referrer. Or they may note a high motivation to family therapy on the referrer’s part and request that the therapist, before embarking on a discussion of the problem with the family, checks out thefamily’s commitment to the idea of therapy. (For a more detailed discussion of the position of the referring person, see Palazzoli et al., 1980.) Once the session is underway, the consultants, beng only indirectly involved with the activity of therapy, can concentrate on evolving a hypothesis using the information which is being produced by the family and the therapist. They can also suggest questions to the therapist who becomes stuck or immersed in inappro- priate detail. The consultants, having more time to think and being more detached, are often able to generate more concise and apposite questions than can the therapist.

Towards the end of the interview, the therapist comes behind the screen for a consultation with the rest of the team. Often the consultants and the therapist will be in accord about a hypothesis, having registered the same information as significant. Often the contributions to such a hypothesis differ. The therapist might be able to convey information about less tangible features such as the atmosphere and the presence of tearfulness and edginess, which are not always clearly apparent through the screen. The consultants on the other hand can sometimes contribute greater precision and clarity because of their more detached position. If agreement on an appropriate hypothesis is reached, discussions will take place about an intervention. Frequently, a number of interventions seem possible, so the pros and cons of each of them are weighed until the team has selected the intervention which it thinks is the most germane and hence, hopefully, the one which will make the most impact.

The consultants frequently coach the therapist in memorizing the salient points of an intervention before it is delivered to the family. On

A team approach 279

occasion, the therapist may have to make it clear that no more can be absorbed if the consultants are continually modifying and adding to the intervention as he/she attempts to memorize it. The consultants can also coach the therapist in hidher delivery of the intervention, ensuring that non-verbal behaviour, tone of voice, etc., are appropriate to the content of, and intention behind, the intervention. The consultants can remind the therapist, for example, to look puzzled if puzzlement is to be expressed or to look directly at particular family members at particular points in the intervention.

At times, team members disagree, not only about the hypothesis but also about which intervention is the most appropriate. As already mentioned, this may result in either the therapist over-riding the consultants or the therapist allowing the consultants’ opinions to hold sway. On other occasions, the team has used such differences of opinion between the consultants and therapist (or between different consultants) as the intervention itself, in the belief that both positions will be reflecting some ‘reality’ in the family. These ‘real’ differences may sometimes be settled during the consultation but, nevertheless, still be presented to the family as if they had not been resolved (see Cade, 1980).

One stage of therapy where consultants are particulary vital is, as Papp (1977) indicates, when the therapist and the therapy has become stuck. One of the authors had been seeing a Canadian couple in their thirties with two children, the family havingmoved to Britain because of the husband’s work. The couple were referred by their general practi- tioner because of dissatisfactions with the marriage which went back seven years for the husband but only recently began for the wife, following her discovery of an affair her husband was having. The therapy during the initial sessions focused on the marital relationship and a number of, what seemed to the team at the time, incisive interventions were made but with little effect. The husband remained un- decided as to whether he wished the marriage to continue and the wife, apparently wanting it to continue, complained about, and was extremely upset by, her husband’s lack of commitment. The therapist saw the couple as motivated and insightful, looked forward to seeing them and was optimistic about the possibility of change. The consultants, in comparison, were growing pessimistic, seeing therapy as stuck with the therapist having been incorporated into the system. Eventually, when nothing did change, the therapist was persuaded of the consultants’ view and all agreed it was necessary to take a wider view.

During the ensuing consultation one of the consultants, talking about the therapist having been ‘sucked’ in, speculated upon whom the


therapist might be replacing in the couple’s relationship. The therapist reminded the team of the family’s commitment to the church when they were in Canada and their high degree of involvement with extended family on both sides. A new hypothesis was evolved. The couple’s marriage and the family as a whole had been in a balance whilst they were in Canada because of involvement with relationships outside the marriage. When the family came to Britain, they lost these other outside relationships, so that more pressure had been put on the family and the marriage. This had caused great discomfort and the husband had had an affair which he had made known to his wife. The couple had then begun therapy, a relationship which, like the affair, relieved some of the pressure on the marriage. (During the course of the therapy, the wife telephoned the therapist repeatedly, engaging her in long conversations about how her husband was letting her down.)

Armed with this new hypothesis, the therapist discovered during the session that the couple had indeed lost many important relationships when they came to Britain and that they had particularly missed a couple to whom they had been very close for about seven years (from which time the husband had dated his dissatisfactions). The two women had been very involved with each other and had met every day to shop, talk and go jogging. As the couple left at the end of this session, the husband said lightly to the therapist, ‘Keep jogging’. This allusion to his wife’s and her friend’s shared activity seemed to add weight to the hypothesis that the therapist had been drawn into the marital relationship as a replacement stabilizer. The consulting group had thus been able to step back and consider the family-plus-therapist system and offer a hypothesis which began to unstick the therapist and the therapy.

Why teams?

Over the past few years, a number of teams have arisen in Europe and North America in the context of the practice of family therapy. Why this has occurred and why in the field of family rather than individual or group therapy is itself a phenomenon of interest but beyond the scope of this paper. Though the use of such a team approach is apparently growing, doubts are sometimes expressed about its necessity. For example, Wright comments: To hear some descriptions of family work, the experience is akin to drowning and increasingly, to retain their potency, therapists hunt in pairs or have back- up teams to ensure their emotional survival. It is not overly cynical to suggest that without this sense of danger the ‘buzz’ that surrounds much of this style of work would be lacking (Wright, 1981).

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Whilst it is tempting to dismiss these assertions as polemic, it is nevertheless necessary to deal with criticisms of the use of teams in family work. Working with consultants can generate problems not produced by the use of a single therapist and the use of a group appears expensive of staff time, even when the number of sessions given to any one family may be relatively few.

The main argument often put forward in favour of teams is increased effectiveness. The degree of difficulty of the problems in many disturbed families is seen as such that, in order to produce change, a number of experienced therapists are necessary to wrestle with the complexities. This belief is one that is shared by a number of groups using a team approach (see Hoffman, 1981 ; Palazzoli, 1978). Severely dysfunctional families can be seen as able to ‘eat therapists for breakfast’ in the sense that the complexities and multiple levels of their communications can rapidly render a therapist confused and hence impotent. A stance of relative detachment seemsmore easilymaintained by a team who, unlike a lone therapist, are a system in themselves, the strength of which position appears to protect them from becoming unhelpfully over- involved with the family and the therapy hence taking much longer or not being productive of change. It can also be argued that a team is less likely to take a biased position in favour of one or another family member. Boscolo and Cecchin (1982) point out that with a number of observers, each person’s viewpoint in the family can potentially be taken by team members and that eventually a range of punctuations of family events can be formed into a hypothesis leading to an intervention which is more truly systemic.

In addition to offering greater levels of detachment, a consulting team can make a significant contribution to the creativity of the therapy. There is often a sparking off within the team of contributions via discussion, free association, apparently ‘out of the blue’ ideas, even humour (see Cade, 1982). An example of such a creative process arose in a sequence of interchanges between consultants and therapist during a consultation towards the end of a therapy session. The therapist could not grasp what the consultants were saying about an intervention so in semi-exasperation she suggested that she went back to the family taking her male colleague with her to give the intervention himself. She would say that for some reason she had become very preoccupied and had been unable to concentrate on what her consultants had been saying to her and so had brought one of them in to help. The look of shock on her colleague’s face at the prospect of being taken in to face a somewhat ‘critical and defensive’ family, led to an explosion of laughter. This


seemed to free the therapist to think clearly and she was able at last to make sense of what her colleagues had been trying to explain to her. But the interchange also resulted in the therapist deciding to commence the intervention to the family by commenting on her strange preoccupation which had led her to make copious notes of her colleagues’ comments. This seemed to be an important addition to the intervention as it mirrored the wife’s obsessional behaviour and preoccupation with thinking over and over things in her head and making endless lists.

A further important function of a consulting group, seems to be the power which apparently becomes vested in it by the family. As Hoffman (1981) and Papp (1977, 1980) indicate, working with colleagues behind a screen conveys mystery and drama to the therapy and for that reason gives the therapy more leverage. All therapists are concerned with the issue of how to be in a position of influence with a family and the use of a team can be one way of achieving such influence. This arises not only from the consulting group’s contributions of relative detachment and creativity but also from the use of the colleagues-behind-the-screen’s opinions, behaviour and feelings as integral parts of the interventions themselves made to families (see Papp, 1980; Cade, 1980; Breunlin and Cade, 1981).

So far, the belief that a team approach is an effective one in family therapy appears to rest entirely on the subjective experience of a number of teams since no systematic research findings have to date been published. Follow-up studies of families seen by teams are being done by a number of groups, for example, the Charles Burns Clinic in Birmingham, the Ackerman team in New York, the Milan Group and at the Family Institute, Cardiff, but so far no data has been published.

Over the past few months, the authors have been working on a questionnaire which will be administered to families after a minimum period of one year following their last session at the Institute. This work has so far produced data on a pilot sample of eight families of which five reported improvements, two stated their situation was the same whilst one refused to co-operate in the follow-up interview. This improvement rate might be considered particularly significant when it is taken into account that the team is working with difficult and disturbed families who frequently have a long history of failed psychiatric and psychothera- peutic treatments.

Nevertheless, as in most research into the outcome of therapy, the question inevitably arises of what, if anything, has been the effective ingredient of the therapy? Even if it can be established that the therapy itself has been potent, how can we know that it was the particular style

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of interviewing, particular techniques of intervention or in this case, the use of a team which has been the significant factor? It is arguable that if the effectiveness of the therapy can be established, then by definition, the team too has been proved effective in that the two are bound together. But this is open to debate; it is possible that a lone therapist using identical theories and techniques could be as effective as a team. From our vantage point at present, we would expect this not to be so; we would expect the lone therapist to become more easily incorporated by these difficult families and rendered impotent. As yet, this has not been tested.

Hard data then does not exist to justify the use of teams in family therapy. Support so far comes from clinical experience alone; a sense of increased effectiveness. It may be that this belief itself is a powerful ingredient of any such effectiveness. Rosenthal(1966) has shown that the beliefs and expectations of interviewers strongly affect their behaviour and hence outcome. If working in teams helps to generate a sense of optimism about the possibility of change, then arguably change is more likely to occur. It is probably true to say that working in teams has developed not only because teams engender optimism about effectiveness but also because the process of achieving any such effectiveness is more satisfying. Family therapy is always difficult, sometimes nerve racking and sometimes depressing; working in teams can be creative, highly supportive, challenging and very often fun. Wright (1981) is correct in his assumption that teams ensure emotional survival; for the authors, a team ensures that clinic days become days to look forward to. It is our belief that such survival and enthusiasm are themselves two contributions of considerable value in what can be offered to a family.

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a team approach to therapy

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